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AbstractObjectiveTo assess the efficacy and safety of different endoscopic surgical treatments for benign prostatic hyperplasia.DesignSystematic review and network meta-analysis of randomised controlled trials.Data sourcesA comprehensive search of PubMed, Embase, and Cochrane databases from inception to 31 March 2019.Study selectionRandomised controlled trials comparing vapourisation, resection, and enucleation of the prostate using monopolar, bipolar, or various laser systems (holmium, thulium, potassium titanyl phosphate, or diode) as surgical treatments for benign prostatic hyperplasia. The primary outcomes were the maximal flow rate (Qmax) and international prostate symptoms score (IPSS) at 12 months after surgical treatment. Secondary outcomes were Qmax and IPSS values at 6, 24, and 36 months after surgical treatment; perioperative parameters; and surgical complications.Data extraction and synthesisTwo independent reviewers extracted the study data and performed quality assessments using the Cochrane Risk of Bias Tool. The effect sizes were summarised using weighted mean differences for continuous outcomes and odds ratios for binary outcomes. Frequentist approach to the network meta-analysis was used to estimate comparative effects and safety. Ranking probabilities of each treatment were also calculated.Results109 trials with a total of 13 676 participants were identified. Nine surgical treatments were evaluated. Enucleation achieved better Qmax and IPSS values than resection and vapourisation methods at six and 12 months after surgical treatment, and the difference maintained up to 24 and 36 months after surgical treatment. For Qmax at 12 months after surgical treatment, the best three methods compared with monopolar transurethral resection of the prostate (TURP) were bipolar enucleation (mean difference 2.42 mL/s (95% confidence interval 1.11 to 3.73)), diode laser enucleation (1.86 (−0.17 to 3.88)), and holmium laser enucleation (1.07 (0.07 to 2.08)). The worst performing method was diode laser vapourisation (−1.90 (−5.07 to 1.27)). The results of IPSS at 12 months after treatment were similar to Qmax at 12 months after treatment. The best three methods, versus monopolar TURP, were diode laser enucleation (mean difference −1.00 (−2.41 to 0.40)), bipolar enucleation (0.87 (−1.80 to 0.07)), and holmium laser enucleation (−0.84 (−1.51 to 0.58)). The worst performing method was diode laser vapourisation (1.30 (−1.16 to 3.76)). Eight new methods were better at controlling bleeding than monopolar TURP, resulting in a shorter catheterisation duration, reduced postoperative haemoglobin declination, fewer clot retention events, and lower blood transfusion rate. However, short term transient urinary incontinence might still be a concern for enucleation methods, compared with resection methods (odds ratio 1.92, 1.39 to 2.65). No substantial inconsistency between direct and indirect evidence was detected in primary or secondary outcomes.ConclusionEight new endoscopic surgical methods for benign prostatic hyperplasia appeared to be superior in safety compared with monopolar TURP. Among these new treatments, enucleation methods showed better Qmax and IPSS values than vapourisation and resection methods.Study registrationCRD42018099583.

Background Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms (LUTS) in aging men, and significantly affects their quality of life and productivity. In Brazil, where most of the population relies on the Public Health System (SUS), transurethral resection of the prostate (TURP) and simple prostatectomy (SP) are the primary surgical modalities. These procedures vary in cost-effectiveness, influencing clinical decisions and healthcare resource allocation. Therefore, we aimed to describe the perioperative outcomes of surgical modalities (TURP and SP) and the financial impact of these treatments in major Brazilian regions in recent years. Method This ecological study utilized data from the Brazilian Public Health System database (DATASUS) from 2009 to 2022. The records of patients diagnosed with BPH and undergoing TURP or SP were analyzed across Brazil’s major geographic regions. The key outcomes included annual surgery volumes, patient demographic characteristics, hospitalization characteristics (e.g., length of stay and intensive care unit utilization), intrahospital mortality rates, and government reimbursements to hospitals. Statistical analyses included descriptive statistics, comparisons between the two techniques, and regression models to assess the temporal trends in mortality rates. Results Over the 14-year period analyzed, Brazil recorded 204,358 BPH surgeries, with the Southeast region accounting for 46.56% of the procedures. TURP was the predominant procedure nationwide (61.44%), particularly in the higher-income regions. Perioperative outcomes favored TURP, with lower intrahospital mortality rates (0.25% vs. 0.55% for SP) and shorter hospital stays (median, 3 days vs. 5 days for SP). Both procedures resulted in decreasing mortality trends, although the differences were not statistically significant. Government reimbursements for hospitals were lower for TURP than for SP and did not keep pace with inflation during this period. Conclusion This study underscores the prominent role of the Southeast region in BPH surgeries within Brazil's public health system and highlights TURP’s favorable perioperative outcomes of TURP over SP. It also showed a financial deficit in surgery reimbursements, which may impact the sustainability of the public health system.

Introduction Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. The number of TURPs performed has declined significantly over the last three decades owing to pharmaceutical therapy. TURP data from a single institution for the years 1990, 2000 and 2010 were compared to assess the difference in performance. Methods A retrospective analysis was undertaken of all patients who underwent TURP between January and December 2010. These findings were compared with historical data for the years 1990 and 2000: 100 sets of case notes were selected randomly from each of these years. Results The number of TURPs performed fell from 326 in 1990 to 113 in 2010. The mean age of patients increased from 70.6 years to 74.0 years. There was also a significant increase in the mean ASA grade from 1.9 to 2.3. The most common indication for TURP shifted from LUTS to acute urinary retention. No significant change in operating time was observed. The mean resection weight remained constant (22.95g in 1990, 22.55g in 2000, 20.76g in 2010). A reduction in transfusion rates was observed but there were higher rates of secondary haematuria and bladder neck stenosis. There was an increase from 2% to 11.5% of patients with long-term failure to void following TURP. Conclusions The number of TURPs performed continues to decline, which could lead to potential training issues. Urinary retention is still by far the most common indication. However, there has been a significant rise in the percentage of men presenting for TURP with high pressure chronic retention. The number of patients with bladder dysfunction who either have persistent storage LUTS or eventually require long-term catheterisation or intermittent self-catheterisation has increased markedly, which raises the question of what the long-term real life impact of medical therapy is on men with LUTS secondary to benign prostatic hyperplasia who eventually require surgery.

BackgroundTransurethral resection of the prostate is the most commonly performed procedure for the management of benign prostatic obstruction. However, little is known about the effect surgical duration has on complications. We assess the relationship between operative time and TURP complications using a modern national surgical registry.MethodsWe queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2006 to 2016 for patients undergoing TURP. Patients were separated into five groups based on operative time: 0–30 min, 30.1–60 min, 60.1–90 min, 90.1–120 min, and greater than 120 min. Standard statistical analysis, including multivariate regression, was performed to determine factors associated with complications.Results31,813 patients who underwent TURP were included. The overall complication rate was 9.0% and increased significantly with longer surgical duration (p < 0.001). Longer operative time was associated with a greater risk of postoperative sepsis or shock, transfusion, reoperation, and deep vein thrombus or pulmonary embolism. Longer surgical duration was associated with increased odds of any complication and, specifically, blood transfusion after controlling for age, race, comorbidities, American Society of Anesthesia (ASA) class, type of anesthesia administered, and trainee involvement. The adjusted risk of each of the above complications remained significantly increased for surgeries lasting longer than 120 min.ConclusionsAs surgical duration increases, there is a significant increase in the rate of complications after TURP. These data demonstrate that this procedure is safest when performed in under 90 min.

We assessed the lower urinary tract symptoms (LUTSs) and clinical outcomes between diabetes mellitus (DM) patients and non-diabetic (non-DM) patients receiving transurethral resection of prostate (TUR-P). This analysis was a retrospective cohort study using 13 years (2000-2012) of claims data from Taiwan's National Health Insurance Research Database (NHIRD). A total of 4,887 patients who had persistent LUTSs and underwent TUR-P for prostate enlargement (benign prostate enlargement [BPE]) were enrolled and divided into two groups: DM and non-DM groups. The patients' characteristics, postoperative clinical outcomes, and the medication records after TUR-P were compared. Chi-square test was used for categorical variables and independent samples -test for continuous variables. Multivariable logistic regression analysis was used to compare the risk of postoperative outcomes. Finally, we estimated the medication-free survival rate after TUR-P using Kaplan-Meier method and compared it between study groups using log-rank test. DM group patients had a higher prevalence of comorbidities. Postoperatively, the DM group had lower rates of urinary tract infection (UTI; odds ratio [OR], 0.78; =0.009) and higher rates of urinary retention requiring catheterization (OR, 1.35; =0.01) within 1 month after TUR-P. A higher proportion of patients with DM took anti-muscarinics (OR, 1.23; =0.032) within the first 3 months and α-blockers (OR, 1.18; =0.049) during 3-12 months after receiving TUR-P. Overall, the DM group patients had a worse postoperative medication-free survival compared to that of non-DM group patients (95% confidence interval [95% CI], 1.14; =0.005). DM patients require higher rates of continuing medication after TUR-P, especially anti-muscarinics in 3 months postoperatively and alpha-blocker after 3 months postoperatively. DM patients also had higher incidence of urine retention after surgery. DM patients had relatively poor treatment outcomes compared to DM-free patients.

Readmission from urological surgery is common, with a readmission rate for day case surgery of 3.7% and 26% for robot-assisted cystectomy. Readmission to secondary care and representation to primary care are both expensive and preventable. This project aimed to reduce both and also enhance the care of patients following urological surgery in a large tertiary referral centre, within the National Health Service. A retrospective telephone follow-up (TFU) survey was set up in the early postoperatively period to measure reattendance and readmission rates and perception of care received. Patients were also asked to suggest how improvement could be made. Quality improvement tools were used to optimise and review the methods and timing of TFU. TFU was initiated as a strategy to enhance care and reduce readmission rates. Phone calls were targeted to occur between 48 and 72 hours following discharge. During the intervention period, 484 phone calls were attempted with 343 being successful. Reattendance rates were reduced by 13% and patient satisfaction improved by 19.6%, following TFU. This intervention also generated additional income for the organisation and enhanced patient satisfaction in the early postoperative period.

BackgroundTransurethral prostatectomy (TURP) is a common surgical intervention for chronic lower urinary tract symptoms (LUTS). Little large-scale evidence exists on factors related to receipt of non-cancer-related TURP.MethodsA prospective study of men aged ≥45 years participating in the 45 and Up Study, a large Australian cohort study, without prior prostatectomy and/or bowel/genital/urinary-tract cancer; questionnaire data were linked to hospitalisations and deaths. HRs for TURP were estimated in relation to multiple factors, adjusting for confounders.ResultsThere were 3416 incident TURPs among 106 769 men (median follow-up 5.8 years), with rates of 1.8, 5.3, 9.1 and 11.4/1000 person-years for ages 45–54, 55–64, 65–74 and ≥75 years, respectively. Age-adjusted rates of TURP varied markedly according to baseline LUTS from 2.2/1000 person-years with no/mild symptoms to 30.7/1000 person-years with severe symptoms. Annual household income ≥$70 000 versus <$20 000, having private health insurance and living in major cities were associated with higher TURP rates; there were no significant differences according to baseline diabetes, stroke, high blood pressure or cardiovascular disease. Men reporting severe versus no physical functioning limitation, high versus low psychological distress or poor versus excellent self-rated health were 36–51% more likely to undergo procedures overall, but were 24–37% less likely to undergo procedures following additional adjustment for need (baseline LUTS).ConclusionsTURP rates were most strongly related to baseline LUTS and age, consistent with appropriate health services targeting. Lower TURP rates in men experiencing socioeconomic disadvantage and with poor health/disability, after accounting for baseline LUTS, suggest inequity and factors such as frailty and risks related to surgery.

A systematic review has been performed on venous thromboembolism after surgery for benign prostatic hyperplasia. The risk of deep vein thrombosis is two to four times higher after open surgery than after transurethral resection. The risk after the newer transurethral methods (laser, radiofrequency, heat) is not known. Specific studies on thromboprophylaxis are few and have limited numbers of patients. Nonetheless, thromboprophylaxis (heparin) reduces the frequency of postoperative deep vein thrombosis after open surgery. Studies on patients undergoing transurethral resection are lacking. Antifibrinolytic treatment to diminish bleeding does not seem to increase the risk of thrombosis.

Only few studies have assessed the safety and efficacy of transurethral surgery (TS) for the treatment of benign prostatic obstruction (BPO) in patients on oral anticoagulants. The aim of our study was to evaluate current treatment strategies and complication rates of TS for the treatment of BPO in patients on OA using an online survey. A total of 300 German departments of urology received an e‑mail with a link for the online survey. The items of the questionnaire assessed the present practice of TS for BPO in patients on OA and the occurrence of complications. Seventy-five (23.4 %) departments responded to the online questionnaire. Of the respondents, 94.7 % performed TS in patients with BPO on OA and 42.7 % answered that they perform more than 30 prostate surgeries per year under OA. The respondents indicated that surgeries were carried out under aspirin (96 %), clopidogrel (46.7 %) or phenprocoumon (26.7 %). Indications for surgeries under OA were made by cardiologist recommendation (82.7 %), the surgeon (37.3 %), a need for emergency surgery (52 %), or the patient's will (10.7 %). Sixty-two (82.7 %) of the respondents perform bipolar or monopolar transurethral resection of the prostate (TUR-P) in patients on OA. In addition, 69.3 % of the respondents indicated that they use laser prostatectomy in patients on OA (thulium 24 %, Greenlight 24 %, holmium 16 %, and diode laser 5.3 %). Cardiovascular complications occurred in 12 % of the respondents. Despite the poor evidence for performing TS of BPO under OA, our survey showed surprising results: TS of BPO under OA is frequently performed, especially bipolar and monopolar TUR-P. Although our data were obtained using an online survey, the complication rates appear to be lower than previously thought.

German residents are becoming increasingly more discontent with their situation. Besides unfriendly working hours and growing bureaucracy the lack of surgical education is considered as causative. Surgical education is assumed to be time-consuming and might impair operative results. Moreover, a number of patients refuse to be misused as a teaching tool. The aim of this study was to compare operative procedures (transurethral resection of the prostate) performed by residents and consultants. All patients underwent monopolar transurethral electroresection of the prostate for symptomatic benign enlargement. All data were collected retrospectively. Mean follow-up to collect functional results and late complications was 70 months. Both groups did not differ significantly in perioperative and postoperative results except for the weight of resected tissue in favor of the consultants group. Functional results and late complications were comparable in both groups. Transurethral resection of the prostate performed by residents is a safe and effective procedure.